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Korean J Gastroenterol  <  Volume 83(4); 2024 <  Articles

Korean J Gastroenterol 2024; 83(4): 163-166  https://doi.org/10.4166/kjg.2024.011
Metastatic Melanoma of the Common Bile Duct Presented with Dyspepsia
Omer Faruk Cetiner1*, Huseyin Emre Dundar2*, Sinem Kantarcioglu-Coskun3, Serkan Torun4, Salih Tokmak4
1Istanbul Faculty of Medicine, Istanbul University, Istanbul; 2Faculty of Medicine, Duzce University, Duzce; 3Department of Pathology, Faculty of Medicine, Duzce University, Duzce; 4Department of Gastroenterology, Internal Medicine, Faculty of Medicine, Duzce University, Duzce, Turkey
Correspondence to: Salih Tokmak, Department of Gastroenterology, Internal Medicine, Duzce University, Konuralp, 81000, Duzce, Turkey. Tel: +905052532698, Fax: +9003805421302, E-mail: salihtokmak@duzce.edu.tr, ORCID: https://orcid.org/0000-0002-2727-5632

*These authors contributed equally to this work.
Received: January 26, 2024; Revised: March 21, 2024; Accepted: April 14, 2024; Published online: April 25, 2024.
© The Korean Journal of Gastroenterology. All rights reserved.

This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Malignant melanoma (MM) is an aggressive tumor that can metastasize to any organ, but biliary tract metastasis is scarce. We describe a very rare case of MM metastasis to the common bile duct (CBD), presented with only dyspeptic symptoms. The patient had mildly elevated alkaline phosphatase and gamma-glutamyl transferase levels. Magnetic resonance cholangiopancreatography demonstrated a dilated common bile duct with a distal stricture. The MM diagnosis was established with the ampulla of Vater biopsy specimens obtained by endoscopic retrograde cholangiopancreatography (ERCP), and the patient’s symptoms were resolved after biliary stenting. Both primary CBD cancer and other cancer types like MM that metastasize to CBD can cause obstruction and can be manifested only by dyspeptic symptoms. MM metastasis to CBD can cause obstruction manifested only by dyspeptic symptoms without obstructive jaundice. ERCP can be employed as a promising option for treatment and diagnosis. New-onset dyspeptic symptoms in patients with a history of MM should be investigated thoroughly, especially in the context of biliary metastasis.
Keywords: Malignant melanoma; Common bile duct; Metastasis; Endoscopic retrograde cholangiopancreatography; Biopsy
INTRODUCTION

Melanocytes are formed from the neural crest, a part of the ectoderm, during embryonic development, and they provide pigmentation by migrating to the whole body.1 Malignant melanoma (MM) is a neoplasm originating from melanocytes in the squamous epithelium, mucous membrane, retina, and uvea.2 MM can metastasize to any part of the body, such as lymph nodes, subcutaneous tissues, lungs, liver, and brain, but biliary tract metastasis is a rare clinical entity.3

Herein, we present a 63-year-old male patient with a history of MM and an obstructive mass in the common bile duct (CBD).

CASE REPORT

A 63-year-old male came to our clinic in September 2021 with complaints of post-prandial abdominal pain and nausea that had been ongoing for over a month. He was diagnosed with MM after the excision of a 2×3 cm mass on his right scapula six months ago. He has been receiving dabrafenib mesylate 75 mg twice daily and trametinib dimethyl sulfoxide 2 mg once daily.

On physical examination, tenderness on deep palpation in the epigastrium was found. The laboratory results showed that alanine aminotransferase 39.00 mg/dL (normal <40 mg/dL) and aspartate aminotransferase 39.20 mg/dL (normal <50 mg/dL) were within normal limits, but alkaline phosphatase 474.00 U/L (normal <120 U/ L), gamma-glutamyl transferase 371.00 U/L (normal <60 U/L), total bilirubin 1.65 mg/dL (normal <1.2 mg/dL), and conjugated bilirubin 0.89 mg/dL (normal <0.2 mg/dL) levels were elevated.

Magnetic resonance cholangiopancreatography (MRCP) demonstrated a dilated (12 mm) CBD with a distal stricture (Fig. 1). Endoscopic-ultrasound examination revealed an irregular stricture in the distal part of the common bile duct. Furthermore, the gallbladder was markedly enlarged, and biliary sludge and crystals were observed. Subsequent imaging showed metastatic lesions in the lungs so endoscopic retrograde cholangiopancreatography (ERCP) was planned to prevent overt obstruction of CBD.

Figure 1. Magnetic resonance cholangiopancreatography (MRCP) image of the dilated common bile duct (12 mm) and the distal stricture (red arrow).

On ERCP, the ampulla of the Vater mucosa was irregular, fragile, and nodular. After obtaining samples for ampullary biopsy, a 10 Fr×5 cm double pigtail stent was placed for drainage (Fig. 2). Dyspeptic symptoms were resolved after the procedure.

Figure 2. Endoscopic retrograde cholangiopancreatography (ERCP) images of the ampulla of Vater mucosa, which was irregular, fragile, and nodular.

In the microscopic examination of the biopsy sample obtained from the ampulla of Vater, clusters of atypical cells with epithelioid appearance were observed and no pigmentation was detected (Fig. 3A, B). Immunohistochemically, tumor cells showed positivity with MelanA and SOX10 (Fig. 3D, E) and negativity with IgG4 and PANCK (Fig. 3C, F).

Figure 3. Clusters of atypical cells epithelioid appearance in the lamina propria, ×4, and ×20, Hematoxylen & Eosin (A, B), adequate IgG4 positive plasma cells were not present ×10, IgG4 (C), tumor cells stained positive with MelanA and SOX10, ×10 and ×20, respectively (D, E), tumor cells showed no immunostaining with PanCK ×10 (F).

The patient developed dizziness and blurry vision one month after the ERCP procedure. MRI images showed metastatic lesions in both hemispheres. His condition rapidly deteriorated, and he died two months after the ERCP procedure.

DISCUSSION

Cases of primary or secondary MM of the biliary tract are scarce. Although the diagnosis of MM in the biliary tract is mostly detected as metastasis, primary cases have also been reported in the literature.4 Unlike many malignancies, MM can be disseminated to almost all organs of the body. Therefore, any symptom in patients with a history of MM should be treated as a consequence of metastatic disease until proven otherwise.5 Patients with MM metastasis in the biliary tract typically present with obstructive jaundice, but dyspeptic symptoms may also occur.6 Unlike the cases in the literature, our patient had only dyspeptic symptoms and didn’t have typical findings on physical examination.

Contrast-enhanced imaging can detect lesions in patients with suspected MM metastasis to CBD.7 However, the final diagnosis requires a histopathologic examination of the tissue samples. To our knowledge, there are less than 20 cases of MM metastasis to CBD in the literature. We confirmed metastatic MM in the ampulla and distal bile duct through biopsy specimens obtained from the ampulla of Vater by ERCP.

Optimal therapy for symptomatic MM metastasis of CBD is up to debate because there are only a few cases in the literature, but if there is any different metastatic focus in a distinct location, palliative treatments may be the best option. Performing ERCP with biliary stenting may yield good results.7,8 Our patient also had immediate relief of his symptoms after ERCP and stenting.

MM is an aggressive tumor that can metastasize to any organ, but metastasis to the biliary tract is scarce. Both primary CBD cancer and other cancer types like MM that metastasize to CBD can cause obstruction and can be manifested only by dyspeptic symptoms. ERCP is a valuable option not only for treatment but also for diagnostic purposes. Additionally, biopsy specimens obtained from the ampullary of Vater can serve as a tool for confirming the possibility of metastasis to the CBD. New-onset dyspeptic symptoms in patients with a history of MM should be investigated thoroughly, especially in the context of biliary metastasis.

Financial support

None.

Conflict of interest

None.

References
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